Ready or Not? 2009

New Report: Nation Scored N/A out of 10 Key Indicators for Emergency Health Preparedness; New Report Finds H1N1 Reveals Gaps in Readiness

Washington, D.C., December 15, 2009 – The seventh annual Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism report, released today by the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), found that the H1N1 flu outbreak has exposed serious underlying gaps in the nation’s ability to respond to public health emergencies and that the economic crisis is straining an already fragile public health system.

Nation achieved N/A out of 10 key indicators of public health emergency preparedness.

Overall, the report found that 20 states scored six or less out of 10 key indicators of public health emergency preparedness. Nearly two-thirds of states scored seven or less. Eight states tied for the highest score of nine out of 10: Arkansas, Delaware, New York, North Carolina, North Dakota, Oklahoma, Texas, and Vermont. Montana had the lowest score at three out of 10. The preparedness indicators are developed in consultation with leading public health experts based on data from publicly available sources or information provided by public officials.

“The H1N1 outbreak has vividly revealed existing gaps in public health emergency preparedness,” said Richard Hamburg, Deputy Director of TFAH. “The Ready or Not? report shows that a band-aid approach to public health is inadequate. As the second wave of H1N1 starts to dissipate, it doesn’t mean we can let down our defenses. In fact, it’s time to double down and provide a sustained investment in the underlying infrastructure, so we will be prepared for the next emergency and the one after that.”

Overall, the report found that the investments made in pandemic and public health preparedness over the past several years dramatically improved U.S. readiness for the H1N1 outbreak. But it also found that decades of chronic underfunding meant that many core systems were not at-the-ready. Some key infrastructure concerns were a lack of real-time coordinated disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity, and a shrinking public health workforce. In addition, the report found that more than half of states experienced cuts to their public health funding and federal preparedness funds have been cut by 27 percent since fiscal year (FY) 2005, which puts improvements that have been made since the September 11, 2001 tragedies at risk.

No. Indicator Nation Number of States Receiving Points
A checkmark means the state received a point for that indicator
1 Purchased 50 percent or more of its share of federally-subsidized antiviral medications to prepare for a potential pandemic flu outbreak N/A 37 and D.C.
2 Submitted data on available hospital beds weekly for at least 50 percent of the facilities within the state to the U.S. Department of Health and Human Services during the 2009 H1N1 response. N/A 40
3 Public health lab has the capacity in place to assure the timely pick-up and delivery of disease samples on a 24/7, 365 day basis. N/A N/A 36 and D.C.
4 Public health lab reports having enough staff to work the intense hours needed during an emergency, like H1N1 (five, 12-hour days for six to eight weeks). N/A 39
5 Tracks diseases through an Internet system used by the CDC. N/A 44 and D.C.
6 Identified the pathogen responsible for reported food-borne disease outbreaks at a rate that met or exceeded the national average of 46 percent (combined data 2005-2007). N/A 36 and D.C.
7 Meets the Medical Reserve Corps (MRC) readiness criteria for medical volunteers during an emergency. N/A 41 and D.C.
8 Requires all licensed childcare facilities to have a multi-hazard written evacuation and relocation plan for emergencies, and verification that the laws are implemented. N/A 20 and D.C.
9 Has a law or legal opinion in place to limit liability against organizations that provide volunteer help during emergencies. N/A N/A 33 and D.C.
10 Increased or maintained level of funding for public health services from FY 2007-08 to FY 2008-09 N/A 23 and D.C.
Total N/A


“State and local health departments around the country are being asked to do more with less during the H1N1 outbreak as budgets continue to be stretched beyond their limits,” said Michelle Larkin, J.D., Public Health Team Director and Senior Program Officer at the Robert Wood Johnson Foundation. “Public health provides essential prevention and preparedness services that help us lead healthier lives — without sustained and stable funding, Americans will continue to be needlessly at risk from the next public health threat.”

The report also offers a series of recommendations for improving preparedness, including:

  • Ensure Stable and Sufficient Funding. The 27 percent cut to federal support for public health preparedness since FY 2005 must be restored, and funding must be stabilized at a sufficient level to support core activities and emergency planning. Increased funding must also be provided to modernize flu vaccine production, improve vaccine and antiviral research and development, and fully support the Hospital Preparedness Program.
  • Conduct an H1N1 After-Action Report and Update Preparedness Plans with Lessons Learned. Strengths and weaknesses of the H1N1 response should be evaluated and used to revise and strengthen federal, state, and local preparedness planning, including assessing what additional resources are needed to be sufficiently prepared. Identified gaps in core systems, including communications, surveillance, and laboratories much be addressed. In addition, continued surge capacity concerns, including establishing crisis standards of care, must be addressed.
  • Increase Accountability and Transparency. Federal and state health departments should regularly make updates on progress made on benchmarks and deliverables identified in the Pandemic and All Hazards Preparedness Act available to the public so they can see how tax dollars are being used and how well protected their communities are from health threats.
  • Improve Community Preparedness. Additional measures must be taken to reach out quickly and effectively to high-risk populations, including strengthening culturally competent communications around the safety of vaccines. Health disparities among low-income and racial/ethnic minorities, who are often at higher risk during emergencies, must also be addressed.

Score Summary:

A full list of all of the indicators and scores and the full report are available on TFAH’s web site at and RWJF’s Web site at For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator. Zero is the lowest possible overall score, 10 is the highest. The data for the indicators are from publicly available sources or were provided from public officials.

9 out of 10: Arkansas, Delaware, New York, North Carolina, North Dakota, Oklahoma, Texas, Vermont
8 out of 10: Alabama, California, Colorado, District of Columbia, Hawaii, Kentucky, Michigan, Mississippi, Ohio, Oregon, Pennsylvania, South Carolina, Wisconsin
7 out of 10: Indiana, Iowa, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, South Dakota, Tennessee, Virginia
6 out of 10: Connecticut, Georgia, Illinois, Kansas, Louisiana, Nebraska, Nevada, New Jersey, New Mexico, Rhode Island, Utah, West Virginia, Wyoming
5 out of 10: Alaska, Arizona, Florida, Idaho, Maine, Washington
3 out of 10: Montana

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need–the Foundation expects to make a difference in our lifetime. For more information, visit